In his rare free moments at home in Kailua, Wayne Pfeffer does his best to enjoy his new Hawaii environment.
At 62, the two daughters are grown, he has remarried and makes sure he takes what time remains to head to the beach and bike paths.
But on the whole, it’s been a steep onramp to his post as director of the Veterans Affairs Pacific Islands Health Care System. In the uproar this spring over extensive wait times for VA patients — reports from Phoenix of dozens dying while waiting for care — Hawaii ended up with the dubious distinction of having the longest wait times in the country.
Then there were the conflicts with Hawaii Congresswoman Tulsi Gabbard, a veteran herself, who said the facts had been misrepresented and who called for Pfeffer’s ouster. The director, who came to the job from a similar post in Kentucky, acknowledged that those were not sunny moments.
Things have improved more recently. This week Pfeffer said the waiting list had dropped by 87 percent. Among the approaches taken, he said, was making better use of existing staff.
The Honolulu-based system extends to Guam and American Samoa and includes neighbor island clinics, but most of the action still happens at the center adjoining Tripler Army Medical Center. About $500,000 has been alloted through September to extend hours and make other improvements, and nurse practitioners on staff have been assigned to more basic patient appointments.
"They weren’t providing the higher-level care because they were hired as RNs (registered nurses)," he added. "So I’ve asked that people maximize their license, and that opened up slots."
Pfeffer hears the stories about the VA being overtaxed by patients who may not qualify for benefits, but said that’s a marginal issue.
"There’s always going to be somebody trying to game or abuse the system — that’s human nature, to a certain extent," he said.
"Our veterans are all deserving of everything we can give them," Pfeffer added. "It’s disheartening when we can’t provide them what they need, or someone has to wait for health care."
QUESTION: Can you provide the current progress of the crackdown on the waiting list of new VA patients?
ANSWER: Absolutely. When I came on board as a director of the Pacific Islands Health Care System, we started looking at waiting times in January pretty seriously. It was about 1,700 patients that were on the waiting list that hadn’t had a scheduled deployment.
When the national issue occurred a few months later, we were listed as 1,400 and some, so we had reduced a little bit. We had a plan to bring it down to no waiting.
As of today we have 186 people on the waiting list. That’s the most current, this morning (Thursday). And each one of those we’ve made three phone calls to their phone number that we have on file. And the ones that we can’t reach, we’ve sent a certified letter asking them within 30 days to let us know if they would like an appointment.
So everybody that wants an appointment, we could schedule in a very timely manner. We’re waiting now to hear back from the veterans. And I don’t think we’ve missed anybody. Obviously, if somebody feels they’re waiting and hasn’t been contacted, please contact us. But my feeling is everybody’s either been reached or for some reason the number’s not good or an address is invalid. We’re hoping they’ll contact us.
Q: How do you think this operation, or the VA more broadly, got to this point to begin with?
A: I think here what happened is Hawaii’s had a steady growth in veterans that have come into our system. We have staffing limitations and space limitations.
So the decision was made — and this was prior to my arrival — that we wanted to give timely, quality care to all the veterans that are in the system. The ones we felt we were too stretched to do ended up on the waiting list.
When I got here, I started looking at what can we do to open up the waiting list and bring everyone in. … And then we kind of dissected different parts of the operation to figure what can we do to open up access.
Q: So basically, the problem was just expansion of the patient load?
A: Exactly. … I think the system as a whole has a different levels of growth, depending on which part of the country. But Hawaii has always had sustained growth. I think it’s because a lot of people get deployed from here.
And we also do American Samoa and Guam under my jurisdiction. As of now, there’s about 600 troops from Guam that are being discharged, and they’re starting to come into our system.
So we constantly have increased demand. It’s a matter of meeting that demand and anticipating future demand so we stay ahead of the pace, so we don’t get back in this position.
Q: Has Hawaii been chronically under-resourced? Shouldn’t this problem have been anticipated?
A: I don’t really want to second-guess before I got here, because I really don’t know how they planned, and what their projections were. But I do know they pretty well reached the saturation point where they decided everyone in the system’s going to get timely quality care and then those who can’t we’ll put on a waiting list and try to deal with the waiting list.
Then when I came, I really looked very seriously about reducing the waiting list.
Q: Would you say the waiting list issues started to grow — when — in the 2000s?
A: I think as the war wound down and more people were discharged. The economy had something to do with it. A lot of people coming into Hawaii. I think it was just demand kept coming up.
Q: Kind of like a perfect storm?
A: Exactly.
Q: How is the relationship with the congressional delegation going? You took a lot of fire from Rep. Tulsi Gabbard, the issue about the statements made before Congress on the waiting time.
A: I think it’s going very well. We have correspondence on a frequent basis from each office, and I’ve talked to a number of congressional people. And I think the congresswoman is very passionate about veterans and very interested in access. As an outlier that Honolulu was, I think it concerned her, and I understand it would.
What I tried to explain — not to go back and beat a dead horse — but it was very complex and confusing. I met not with her but her staffers, and at that point I didn’t know the actual number, which was 145 days. And we were asked at that time not to prematurely release numbers until the national release, which happened to be a few days later.
So what I was trying to explain is the number of people that are on our waiting list, when we call them to come back into an appointment, it was taking 53 days. Right now we’re about two to three weeks, from when we call you. So that got misconstrued, I believe, to that I said the waiting list was 53 days. And I think when 145 days was seen, I think that caused the consternation. And I’ve tried to clarify that.
But I understand her passion. She’s very strongly an advocate for veterans. I think the relationship will get better over time.
I think our numbers are doing well. I think our plans are coming together. I had stated that within about three months I’d like to have no waiting list. And we’re pretty well on track to accomplish that. I think it’s very positive.
Q: How are you getting the waiting list down?
A: A number of things. … One, we’re hiring additional staff; we’re increasing the number of physicians here that see primary care (patients). And we’re also recruiting a physician in Guam right now. And so we’re adding clinical time.
We’re also hiring support staff for the doctors. We found that the doctors, not having the adequate support staff, were doing work when they really could be devoting their time to direct patient care. So that’s given them more time.
The standard here was 1,200 patients were assigned to each primary care physician, which is a relative standard that VA uses, usually 1,200-1,300. So I’ve increased that to 1,300 to open up more access for the clinicians to see more patients.
Also because the new patients weren’t being scheduled in, all the slots per day for clinicians were all established patients. So we’ve asked the minimum of two to three patients a day be new patients. So that helped open up the doors.
We’re working Saturday clinics. In fact, our nurse executive, who’s a nurse practitioner, is coming in on Saturdays and seeing patients. So we’re getting people on Saturdays and evenings to see patients.
Q: Is that a short-term expansion of hours?
A: We’ll do that until we feel it’s not necessary. I would like to have extended hours because I think for patient convenience, some patients that work like to come in on a Saturday, later in the day. I’m hoping to keep that as a permanent solution.
Q: So previous to that, there were no Saturday hours?
A: It was episodic. There were, occasionally, but there weren’t regular Saturday hours. …
Q: What are some of the other plans?
A: We’re looking to build several additional clinics, waiting for the final go-ahead to build, which would decompress space at the clinical addition and hopefully come with the resources to hire staff.
One, called the Aloha Project, is in the Ewa plain area. It’s about double the size of our current facility here.
Q: Is that in Kalaeloa?
A: We haven’t picked an exact location yet, but we want to capture people on the other side of the island that won’t have to come in, and open up space here. …
Q: Going back to the increased patient load for the doctors: Has that curtailed their time to spend on cases?
A: No, we’re keeping the time. I think it’s a matter of changing their practice to hire support staff, to give them more opportunity to see patients.
There’s a time alloted to a specific type of appointment. We haven’t changed that at all. …
Our patients are very complex. It’s not like a private doctor where you come in with the flu, or a cold, and you spend five minutes and get a prescription. …
I haven’t heard where anybody is being rushed through an appointment. I would hope that hasn’t happened.
